Narrative Review of Vascular Iatrogenic Trauma and Endovascular Treatment

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Review Article on Endovascular Interventions in Trauma Page 1 of 21

Narrative review of vascular iatrogenic trauma and endovascular treatment

Tyler Andrew Smith1, David Gage2, Keith Bertram Quencer1

1Department of Interventional Radiology, University of Utah, Salt Lake City, UT, USA; 2Department of Medicine, Intermountain Healthcare, Murray, UT, USA Contributions: (I) Conception and design: All authors; (II) Administrative support: KB Quencer; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Tyler Andrew Smith. Department of Interventional Radiology, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, USA. Email: [email protected].

Abstract: Iatrogenic injury is unfortunately a leading cause of morbidity and mortality for patients worldwide. The etiology of iatrogenic injury is broad, and can be seen with both diagnostic and therapeutic interventions. While steps can be taken to reduce the occurrence of iatrogenic injury, it is often not completely avoidable. Once iatrogenic injury has occurred, prompt recognition and appropriate management can help reduce further harm. The objective of this narrative review it to help reader better understand the risk factors associated with, and treatment options for a broad range of potential iatrogenic injuries by presenting a series of iatrogenic injury cases. This review also discusses rates, risk factors, as well as imaging and clinical signs of iatrogenic injury with an emphasis on endovascular and minimally invasive treatments. While iatrogenic vascular injury once required surgical intervention, now minimally invasive endovascular treatment is a potential option for certain patients. Further research is needed to help identify patients that are at the highest risk for iatrogenic injury, allowing patients and providers to reconsider or avoid interventions where the risk of iatrogenic injury may outweigh the benefit. Further research is also needed to better define outcomes for patients with iatrogenic vascular injury treated with minimally invasive endovascular techniques verses conservative management or surgical intervention.

Keywords: Iatrogenic injury; embolization; adverse event

Submitted May 29, 2020. Accepted for publication Aug 12, 2020. doi: 10.21037/atm-20-4332 View this article at: http://dx.doi.org/10.21037/atm-20-4332

Introduction imaging findings, and potential treatment options with a focus on endovascular and minimally invasive treatments. Although the words “primum non nocere” (Latin for first do We present the following article in accordance with the no harm) are often misattributed to Hippocratic oath, it Narrative Review reporting checklist (available at http:// nonetheless remains a guiding principle for physicians of dx.doi.org/10.21037/atm-20-4332). every specialty. While avoidance of any harm to patients is impossible, interventions which provide a net benefit Methods to patients are frequently undertaken. No treatment is without risk, however harm caused by medical therapy A literature search was conducted using PubMed (US is the exception rather than an expected outcome. The National Library of Medicine, Bethesda, MD, USA). objective of this narrative review is to help the reader better No studies were excluded based on year of publication. understand the risk factors of iatrogenic injury, clinical and Studies which investigated risk factors, rates, clinical signs,

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Figure 1 A 67-year-old male with metastatic melanoma and multiple new pulmonary nodules measuring up to 1.2 cm. Biopsy of one of the pulmonary nodules was requested (A, white arrow). The biopsy was complicated by prompt development of pulmonary hemorrhage (black arrows). imaging findings, and management of iatrogenic injury pneumothoraxes with >35 mm of pleural separation (6). were included, with an emphasis on minimally invasive and endovascular management. Swan-Ganz catheter placement

In patients with difficult to manage cardiogenic shock, Chest pulmonary artery catheterization may be indicated to help with titration of pressor medications and fluid Lung biopsy administration (7). Major and minor complications Lung cancer is the most common cause of cancer related associated with pulmonary arterial catheter placement deaths worldwide (1). Percutaneous biopsy allows for occur in 4.4% and 23% of cases respectfully (8). diagnosis and targeted therapy but is not without risk Complications can include inadvertent arterial puncture (Figure 1). Despite its utility, complications do occur at (approximately 1.9% of cases), pneumothorax (0.5% of a relatively high frequency, with an overall complication cases), catheter induced thrombosis (1.9–22% of cases, rate of 38.8% for CT-guided core biopsy (2). The most depending on site of vascular access), cardiac arrhythmias common complication is pneumothorax, occurring in (12.5–70%), damage to cardiac valves or chordae (0.9%), approximately 25% of biopsies (2) (Figure 2). Hemoptysis and rarely pulmonary arterial rupture or perforation occurs in between 1.7% and 4.1% of patients (2). Other (0.03–0.20%) (9). Case reports have described ventricular rare complications include air embolism and tumor perforation as a potential complication (10). Unfortunately seeding (3). rupture of the pulmonary artery is associated with an Risk factors for pneumothorax include emphysema, overall mortality rate of 53–70% (8). Potential treatment long needle pass, smaller lesions, fissure puncture, multiple options include surgery or minimally invasive endovascular needle passes across the pleura (4). Risk factors for significant procedures (8). A small series of 6 patients who developed pulmonary hemorrhage include deep location, older age, traumatic pulmonary artery pseudoaneurysms following female sex, and emphysema (5). The initial treatment for swan-ganz catheter placement treated with coils, pneumothorax is supplemental oxygen; a chest tube is absorbable gelatin embolics (gelfoam) had a technical indicated if the pneumothorax is symptomatic, growing, or success rate of 100%, with no patient developing recurrent

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Figure 2 A 70-year-old female with an enlarging lung mass. (A) The patient underwent CT needle guided biopsy. (B) The biopsy was complicated by bilateral pneumothoraces (black arrows), known as a buffalo pneumothorax. The patient was treated with a chest tube and required hospitalization for several days before the chest tube could be removed. Bilateral pneumothoraces can be present in patients with incomplete pleural fusion.

Complications associated with thoracostomy tubes can broadly be described as insertional (injuries caused at the time of placement, 14.4–15.3%), positional (malfunction of the tube or damage to structures following a successful placement, 53.1–68.9%), removal (new or persistent pneumothorax, or bleeding 16.2–16.7%), or infection (0– 14.8%) (12,13).

Thoracentesis

It is estimated that approximately one hundred and seventy- Figure 3 A 71-year-old female with a history of myelofibrosis eight thousand thoracenteses are performed annually (14). status post unsuccessful right sided thoracentesis without Common complications include hemorrhage (hemothorax US guidance which was complicated hypotension and and chest wall hematoma), pneumothorax, and re-expansion hemoperitoneum. CTA demonstrated focal extravasation from the pulmonary edema (15) (Figure 3). A cohort study examining right lobe of the liver with high density clot (white arrow). Patient over 9,300 thoracenteses found rates of hemorrhage at subsequently expired of complications of acute blood loss anemia. 0.18%, pneumothorax 0.61%, and re-expansion pulmonary edema at 0.01% (16). Hemorrhage is a rare complication of thoracentesis with an incidence rate from 0.12–2% and hemoptysis and 4 of 6 patients eventually being discharged often due to laceration of an intercostal artery (ICA) or from the hospital (11). an associated branch (Figure 4). Cadaveric studies show increased tortuosity of the ICA within 6 cm of midline, in Chest tube patients older than 60, and in more cephalad rib spaces (17). Physician-performed US was found to be 86% sensitive for Chest tube placement, also known as thoracostomy tube, is a identifying the ICA with median time to locate the vessel of commonly performed procedure for the treatment of pleural 42 seconds for portable US and 18 seconds for high-end US space disease including pneumothorax, empyema, pleural (18). One study including >19,000 thoracenteses showed effusions, and trauma. Reported complication rates from that US guidance was associated with a 38.7% reduction in thoracostomy tube placement are highly variable, ranging hemorrhage and 16.3% reduction in pneumothorax (19). from 1–40%, however a recent meta-analysis of 29 papers Risk factors for pneumothorax include BMI <18, and 949 patients found a complication rate of 19% (12). removing >1,500 mL, and two or more needle passes (16).

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Figure 4 A 55-year-old male, status post thoracentesis. (A) The procedure was complicated by intercostal vascular injury, with contrast pooling adjacent to the ribs, suggestive of active bleeding (black arrow) and the development hemothorax (white arrow). (B) Angiography demonstrated pseudoaneurysm and active extravasation from an intercostal artery (black arrow).

Moderate coagulopathies (considered INR greater than 3 and standard in the workup of fibrosis, chronic hepatitis, and platelets less than 25,000/microL) and mechanical ventilation liver cancer (24,25). Complications include hemorrhage, were not found to increase risk of complications (17). which has been reported from 0–10.9%, with most studies Risk factors for hemorrhage include renal disease, reporting rates less than 2% (26-28). small pleural effusion, obesity, complicated pleural space, suboptimal patient position, lack of operator Transjugular intrahepatic portosystemic shunt (TIPS) experience, lack of ultrasound guidance, and large-volume drainage (15). TIPS treats portal hypertension through the creation of a connection between the portal venous system and hepatic Liver venous system. Technical success rates are high; however, complications can affect patient prognosis and include Percutaneous transhepatic biliary drainage (PTBD) acute liver failure, hepatic encephalopathy, hemorrhage, PTBD allows for relief of malignant obstruction of the biliary injury, thrombosis, and shunt migration or biliary system. There is a high technical success rate of dysfunction (29) (Figure 6). Unfortunately, many patients PTBD, ranging from 91.2–100%, with a non-dilated biliary with portal hypertension and liver disease have elevated system being a common cause for technical difficulty (20). INR and low platelets, further increasing the risk of PTBD has similar therapeutic success rates and overall bleeding (29). Internal jugular vein and hepatic vein access complication rates when compared to endoscopic biliary should be performed under ultrasound and fluoroscopic dilation. However, meta-analysis found PTBD to be more guidance to avoid arterial access or right atrial injury (29). likely to cause bleeding (OR 1.81) and tube dislocation (OR Arterial injuries are rare and occur in less than 2% of TIPS 3.41). Traumatic complications of PTBD include injury to cases (30). If there is an injury to the portal venous system the hepatic artery or portal vein, bile leak, and duodenal patients can suffer rapid blood loss due to underlying perforation (21,22). Studies of PTBD catheter placements portal hypertension, and if significant injury is suspected reported an overall complication rate of ranging from 5.2– portal venography should be performed to identify and 10.8% (20,23) (Figure 5). treat the source of bleed (29). Portal vein dissections can be treated with the extension of the TIPS stent over the dissection flap (31). Liver capsule transgression occurs Liver biopsy in 33% of TIPS cases, however, hemorrhage related to Liver biopsy is a minimally invasive procedure which allows capsule injury only occurs in 1–2% of cases (32). Following for further evaluation of liver pathology and is a gold the procedure liver laceration causing intra-abdominal

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Figure 5 A 51-year-old male with a history of liver transplant and biliary drainage for the treatment of a bile leak. The patient developed significant haemobilia and a drop in hemoglobin, prompting further evaluation. (A) Initial angiogram failed to show the source of bleeding. (B) Once the drain was over a wire removed extravasation from a hepatic artery was seen, with blood leaking into the biliary drain tract (black arrows). (C) This was treated with coil embolization (white arrow).

can be largely avoided with strict adherence to lactulose regimens and protein restricted diets (29). Patients with severe encephalopathy or acute liver following TIPS, stent occlusion should be considered (29).

Transarterial chemoembolization (TACE)

TACE is commonly performed for the treatment of unresectable hepatocellular carcinoma. Major complications are reported in approximately 5% of cases, with a risk of death approaching 1% (34). Arterial access is Figure 6 A 58-year-old male with portal hypertension who required for TACE, and although complications related to was undergoing TIPS placement for refractory ascites. Portal puncture site is rare, hematoma may develop in up to 2% venogram demonstrated a brisk capsular bleed (black arrow). of patients and rarely pseudoaneurysm of arteriovenous Despite best medical management in the ICU and repeated fistula may develop (34). Hepatic and celiac artery injury transfusions the patient subsequently expired. TIPS, transjugular including arterial spasm, dissection, or thrombosis are intrahepatic portosystemic shunt. more common and observed in 0.5–2.7% of cases (35) (Figure 7). Due to the high rates of normal variants in hepatic arterial anatomy, non-target embolization is a hemorrhage has been reported up to 8 days following potential complication, and can cause significant iatrogenic TIPS in patients treated with heparin, and case reports injury (34). Common sites of nontarget embolization have reported hemorrhage up to 2 weeks following the include gastric arteries, gastroduodenal artery, cystic procedure in patients treated with heparin or warfarin artery, parasitized blood supply from the inferior phrenic (29,33). Patients who are able to tolerate a brief cessation artery, and even cutaneous branch embolization such of anticoagulation can avoid the rare but potentially as the superior epigastric artery (34). Arteriovenous morbid complication (29). Hepatic encephalopathy occurs shunting or porto-venous shunting can result in in 5–35% of patients following TIPS and can occur days pulmonary embolization (34). Following the procedure or months after placement, however this complication post embolization syndrome (fever, malaise, right upper

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Figure 7 A 75-year-old male with hepatocellular carcinoma. (A) Initial MRA showed a normal celiac trunk (white arrow). (B) Initial celiac angiograms showed normal vessels, with a normal celiac trunk (black arrow). (C) After catheterization and intervention, hepatic angiogram showed a dissection of the celiac trunk (black arrow). (D) Subsequent CTA demonstrated a flow limiting dissection of the celiac trunk with thrombosis of the false lumen (white arrow). The patient was treated with stent placement, which resumed normal flow to the celiac trunk (not pictured). quadrant pain, nausea and vomiting) is observed in up to undergoing core needle biopsy of the spleen reported an 90% of patients (34). Infection following TACE can be overall complication rate of 8.2%, but a major complication seen in 2–3% of patients receiving prophylactic antibiotics, rate of 1% (hemothorax requiring chest tube, transfusions, and 11% of patients without prophylactic antibiotics (36). and embolization of bleeding pseudoaneurysm) (37). Another recent study reviewing 52 cases of core needle splenic biopsy reported a major complication rate of 0% Spleen and a minor complication rate of 1.9% (44). Given the Pathologies that involve the spleen are numerous, and recent reports of low complication during splenic biopsy, include infection, malignancies including lymphoma, it should not be withheld when pathologic diagnosis is leukemia, and melanoma, and systemic diseases. clinically indicated (37). Differentiating splenic pathology can be difficult to The spleen can also be injured during therapeutic diagnose based on imaging characteristics alone, therefore embolization. Splenic partial embolization is often indicated histologic evaluation is often indicated (37). Unfortunately, in patients with hypersplenism and thrombocytopenia, early reports of core needle splenic biopsy found high rates and can avoid risks associated with surgical splenectomy of major bleeding (38). Subsequent series using fine needle including portal and mesenteric vein thrombosis and post aspiration reported no bleeding complications, but at the splenectomy infection (45-47) (Figure 8). Although partial expense of limited diagnostic utility (37,39). More recent splenic embolization has advantages over splenectomy, this studies with small sample sizes or using pooled data from procedure is not without risk, and reported complications both fine needle aspiration and core needle biopsy reported include post embolization syndrome, pneumonia, low complication rates (40-43). A 2016 study of 97 patients atelectasis, or abscess (45). Splenic abscess has a high

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Figure 8 A 88-year-old male with multiple medical problems who presented with fever and abdominal pain following therapeutic splenic embolization for hypersplenism and thrombocytopenia. (A) Contrast enhanced CT was performed and demonstrated a splenic abscess (white arrow). (B) The abscess was initially treated with percutaneous abscess drain (black arrow). After the drainage catheter was removed the patient became hypotensive. Interventional radiology was consulted for splenic artery embolization. (C) Initial splenic artery angiogram demonstrated extravasation of contrast from distal splenic vessels adjacent to the abscess cavity (black arrow). (D) Mid splenic artery embolization was performed (black arrow), and the patient’s hemodynamic status improved. mortality rate (reported up to 16%), and occurs in 6.8% One study which included 500 consecutive percutaneous of patients undergoing splenic embolization (48-50). renal biopsies found a major complication rate of 2.4% Once splenic abscess is identified, appropriate treatment and 41.2% minor complication rate (53). There were with antibiotics and surgical or catheter abscess drainage no deaths reported in this study, but 1.8% of patients can reduce mortality rate to 5.6% (48,51). Prophylactic required blood transfusions, and one patient required antibiotic therapy is indicated for these patients to reduce endovascular embolization (53). Minor complications risk of infection (48). included hematoma detected by imaging, drop in hemoglobin greater than or equal to 1 g/dL, and Renal hematuria (53). Another more recent retrospective study of 644 patients reported major bleeding in 4.3% Renal biopsy of cases (28 total patients). Of these patients, 4 required Percutaneous renal biopsy is a commonly performed endovascular embolization and 1 required surgery to procedure to diagnose renal disease, however this control bleeding (52). Interestingly they found the only procedure is not without risks. The most commonly patient characteristic that was associated with a need for reported major risk is severe bleeding (52) (Figures 9-11). blood transfusion was baseline hemoglobin at the time

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Figure 9 A 51-year-old female status post biopsy of an atrophic right kidney (A, white arrow). Following the biopsy, the patient experienced dropping blood pressure and hypotension. (B) Subsequent non-contrast CT demonstrated a large hematoma in the right retroperitoneum (white arrow). (C) Angiography of the kidney was performed. (D) Since the kidney had minimal function at baseline, the whole kidney was embolized with coils (white arrow).

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Figure 10 A 77-year-old male with elevated creatinine. Following kidney biopsy, the patient presented with hypotension. (A) The patient was taken urgently to angiography which demonstrated small pseudoaneurysms in the inferior pole (black arrow). (B) Selective angiography demonstrated extravasation of contrast from pseudoaneurysms (black arrow). (C) Coil embolization was performed (black arrow), and post embolization angiography showed complete devascularization of the injured renal artery.

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Figure 11 A 46-year-old female with medical renal disease who underwent routine biopsy. Shortly after the biopsy the patient developed gross hematuria. (A) Urgent angiography was performed and demonstrated a pseudoaneurysm arising from a segmental artery in the inferior pole of the right kidney (black arrow). (B) Coil embolization was performed (black arrow) and post embolization angiography demonstrated complete devascularization of the injured artery. of biopsy, with an odds ratio of 13.6 for patients with a Percutaneous cryoablation hemoglobin less than 10 (52). Percutaneous cryoablation is frequently used to treat renal masses, especially in patients who are poor surgical Percutaneous nephrostomy (PCN) candidates. One multi-institutional review of 271 PCN is a minimally invasive technique that involves radiofrequency and cryoablation treating small renal placing a small catheter into the renal collecting system. tumors found an overall complication rate of 11% (56,57). Four broad indications include relief of obstruction, A more recent study of 573 procedures using cryoablation diagnostic testing such as antegrade pyelography, access and radiofrequency ablation to treat small renal tumors for interventions, and urinary diversion (53). The found an overall complication rate of 11%, with a 6.6% combined major and minor complication rate from PCN major complication rate (56). There was no difference in is approximately 10%, with a mortality rate ranging from major complication rate between radiofrequency ablation 0.05–0.3% (52). One study of 318 PCN cases found a and cryoablation for treating small renal tumors (56). One major complication rate of 3.1%, with sepsis being the study looking at only cryoablation found a complication most commonly reported major complication (2.2%) (54). rate of 12.4% (6.5% major), and a local recurrence rate of Major hemorrhage was encountered in 0.6% of cases (54) 8.3% (58). The most common complications following (Figure 12). Death was reported in 2 patients, both due renal cryoablation are bleeding and hematuria, with to sepsis (54). Standards of Practice published by the bleeding occurring in 4.8% of cases (56) (Figure 13). Of Society of Interventional Radiology summarizes the most the patients that experience bleeding, embolization is commonly encountered major complications from PCN indicated in approximately half of cases (56). Increased placement, citing septic shock as the most frequent major size and central location of tumors were at greater risk of complication (1–10%), with rates of septic shock reaching complication (56). Use of the modified RENAL (mRENAL) 7–9% in patient with pyonephrosis (55). Other major score has been shown to be a useful tool in predicting complications include hemorrhage requiring transfusion complications and recurrence following renal cryoablation (1–4%), vascular injury requiring embolization or surgery by looking at factors such as lesion size, complexity, and (0.1–0.6%), bowel transgression (0.2–0.5%), and pleural location (exophytic, near collecting system) (58). One study injury (0.1–0.6) (55). investigating the use of the mRENAL score found that

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Figure 12 A 71-year-old male with a left ureteral transection during colon resection with need for PCN. (A) CT of the abdomen demonstrated moderate left hydronephrosis (white arrow). (B) A fluoroscopic guided PCN was placed, however the initial puncture was done too centrally (black arrow). Bright red blood was noticed in the PCN bag, and the patient became hypotensive. (C) Urgent angiography was performed; however, no arterial injury was noted while the PCN drain (black arrows) was still in place. (D) The PCN was removed over a wire and repeat digital subtraction angiography was performed, revealing blood along the PCN tract (black arrows). (E) The injured artery was treated with coil embolization (white arrow), leading to resolution of contrast extravasation. PCN, percutaneous nephrostomy. endophytic location was associated with increased risk of (8.7–12%) (55). One recently published systematic review complications, and that only tumor size was associated with found that the overall complication rate of PCNL was 6.2– increased risk of local recurrence (58). 15.2%, with ultra-micro equipment being associated with lower overall complications (59). No deaths were reported following PCNL for small to medium sized stones (59). Percutaneous nephrolithotomy (PCNL)

PCNL involves percutaneously accessing the renal Endoscopic laser treatments collecting system for the treatment of renal calculi. Risks and complications of PCNL are similar to PCN, however Urothelial carcinoma is a malignancy that involves complication rates tend to be higher than PCN alone (55). the mucosal surfaces lining of the urinary system (60). Standards of Practice published by the Society of The most common site of involvement is the bladder; Interventional Radiology reported the most common however, involvement of the ureters and kidneys can be complication of PCNL was hemorrhage requiring seen in 5–10% of all urothelial carcinoma (60). The gold transfusion in 12–14%, followed by pleural complications standard for treatment of urothelial carcinoma is radical including pneumothorax, empyema, hemothorax nephroureterectomy with bladder cuff excision (60). More

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Figure 13 A 66-year-old male with left sided enhancing renal mass, which was biopsy confirmed clear cell renal cell carcinoma (A, white arrow) undergoing a percutaneous cryoablation (B, white arrow). (C,D,E,F) The procedure was complicated by arterial injury, requiring angiography which demonstrated vascular injury and extravasation of contrast (black arrows). (G) Selective coil embolization was performed leading to complete devascularization of the injured artery (black arrow). recent recommendations published by the European series of 25 patients treated with ureteroscopic laser Urology Guidelines recommend endoscopic treatment ablation of upper pole urothelial carcinoma found that 64% (including ureteroscopic laser treatment) alone for low remained disease free for 3 months, but only one patient grade urothelial malignancies (61). One recently published remained disease free at 68 months (60). Another series

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Figure 14 A 66-year-old male with urothelial cancer status post laser ablation with hematuria. (A) Initial angiogram demonstrated a pseudoaneurysm in the inferior pole of the kidney (black arrow). (B) This was treated with coil embolization of the pseudoaneurysm sac (white arrow). Unfortunately, hematuria continued following embolization. (C) Repeat embolization of the feeding vessels was performed (black arrows), which led to a cessation of hematuria. of 66 patients with low grade upper tract cancer treated system, infection, or tumor recurrence (71) (Figure 15). with laser ablation reported only 15.2% progressing to Delayed hemorrhage after partial nephrectomy has been high grade disease (62). Complications included ureteral reported in up to 2% of cases (72). Rates of hemorrhage strictures, bleeding requiring transfusion, sepsis, and severe due to pseudoaneurysm range from 0.4–1.4% (73,74). ureteral injury (60) (Figure 14). Laser lithotripsy is another technique the urologist Abdominal can use for renal stone ablation, and has a low overall complication rate, which are mostly attributed to Paracentesis endoscopic access rather than the laser itself (63). The most frequently reported complication from laser lithotripsy is Paracentesis is a commonly performed diagnostic and fever, however hematoma and vascular injuries have been therapeutic procedure. Bleeding complications are rare, with reported (63,64). one observational cohort study with 69,859 paracenteses reporting a bleeding complication rate of 0.8% (75) (Figure 16). Another study reported the rate of hemorrhage Partial nephrectomy from paracentesis at 0–0.97%, with risk factors for Partial nephrectomy is commonly performed for the hemorrhage including renal disease, lack of operator treatment of small renal masses. Laparoscopic, robotic experience, and lack of ultrasound guidance (76). Ultrasound assisted, and open techniques are used, with similar guidance has been shown to reduce the risk of bleeding after oncologic outcomes (65,66). Laparoscopic partial paracentesis by 3-fold compared to paracentesis performed nephrectomies have the advantage of decreased operative without ultrasound (75). One retrospective study including time, lower blood loss, and shorter hospital stay, however 3,000 paracenteses performed with ultrasound guidance there are statistically similar complication rates (65). by radiologists found that significant post-paracentesis Meta-analysis comparing robotic assisted partial hemorrhage occurred in only 0.19% of patients, with only a nephrectomy verses open partial nephrectomy found single case requiring embolization despite the fact that INR lower blood loss, decreased length of stay, and decreased was over 2 in 14% of cases and platelets were under 50×10^3/ postoperative complication rates (67-70). Following partial μL in 12% of cases (77). Despite the low hemorrhage rate, nephrectomy injury to the intrarenal arteries can result when blood vessels are injured it is most commonly the in pseudoaneurysm or hematoma, injury to the collecting inferior epigastric artery or vein, therefore identification of

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Figure 15 A 67-year-old male with a small papillary renal cell carcinoma, status post partial nephrectomy complicated by gross hematuria. (A) CT of the abdomen demonstrated dense blood adjacent to the nephrectomy defect (white arrow). (B) The patient was taken to angiography, which demonstrated multiple pseudoaneurysms (white arrows). (C) The injured vessels were treated with coil embolization (white arrow).

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Figure 16 A 52-year-old female with cirrhosis secondary to alcohol use. Following a therapeutic paracentesis without ultrasound for recurrent ascites the patient complained of pain and swelling at the paracentesis site. (A) Coronal CT of the abdomen demonstrated a large rectus sheath hematoma (white arrow), with a focus of active extravasation (blue arrow). (B) Selective angiography with contrast extravasation from the left inferior epigastric artery (white arrow). This was treated with coil embolization (not shown) and the patient’s hematoma resolved. their location by ultrasound prior to paracentesis can further complication rates from percutaneous abscess drain range reduce risk of hemorrhage (78). from 5–9.8% (81). Following percutaneous abscess drain placement transient bacteremia is observed in up to 5% of cases, with septic shock reported in 1–2% of cases (79,82). Drain placement Other potential reported complications include hemorrhage Percutaneous drain placement is one of the most commonly requiring transfusion (1%), superinfection of a previously performed image guided procedures. Technical success sterile fluid collection (1%), bowel transgression requiring rates are high, often exceeding 90% (79). Abscess drain intervention (1%), and pulmonary pleural injury requiring is one of the most common indications for percutaneous intervention (1%) (82) (Figure 17). Complication rates are image guided drain placement, and reduces morbidity and highly dependent on abscess location, patient comorbidities, mortality compared to open surgical drainage (80). Overall and provider experience (82).

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Figure 17 A 66-year-old with diverticular rim enhancing abscess in the left lower quadrant (A, white arrow). (B) A drain was placed into the abscess cavity. After drainage, the patient developed a significant hemoperitoneum (not shown). (C,D) The patient was taken to angiography which demonstrated active extravasation of contrast from an arterial pseudoaneurysm (black arrows). (E) This was treated with coil embolization (black arrow).

Vascular access inhibitor use (83) (Figure 18). Treatment depends on the characteristics and size of the pseudoaneurysm and Vascular access allows providers to administer medications, can include compression, injection of thrombin into the obtain diagnostic labs, and perform diagnostic and pseudoaneurysm, or surgical repair (84). therapeutic procedures. Despite advances in techniques, When venous access is attempted, there is a risk of vascular access is not without risk. Arterial catheterization carries a significant bleeding risk of 1.8–2.6%, with risk inadvertent arterial access or arterial injury. Without factors for significant hemorrhage including number ultrasound guidance the risk of accidental arterial access of attempts, lack of ultrasound guidance, and a high is 15%, but with ultrasound guidance the risk drops entry site when accessing the femoral artery (76). Focal to 1% (85,86). When accidental arterial access occurs, arterial injury as a result of catheterization can also occur, management usually involves endovascular or open surgical resulting in pseudoaneurysm. The most commonly removal and vessel repair (85,86) (Figure 19). Other accessed artery is the common femoral artery (CFA), factors that contribute to arterial injury include previous and risk factors for pseudoaneurysm development at radiotherapy, obesity, lack of operator experience, previous the CFA include advanced age, female gender, obesity, surgery at site of vascular access, and multiple venous hypertension, sheaths greater than 6F in size, post access attempts (85,86). In addition to inadvertent arterial procedure anticoagulation use, and periprocedural P2Y12 access other potential complications include hematoma,

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Figure 18 A 59-year-old female status post right common femoral artery arterial access who presented with increasing right groin pain and swelling. (A) Ultrasound demonstrated a narrow necked pseudoaneurysm with the classic “yin-yang” appearance on doppler ultrasound (white arrow). (B) This was treated with thrombin injection, which led to complete thrombosis of the pseudoaneurysm (white arrow).

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Figure 19 A 59-year-old male status post bedside central line placement. The procedure was complicated by pneumothorax and inadvertent arterial placement. (A) Chest radiograph demonstrating a right sided pneumothorax (white arrow), and a central line which crosses midline and terminates near the level of the left main bronchus, consistent with inadvertent arterial access (black arrows). (B-D) Axial contrast enhanced CT, maximum intensity projection images, and 3D reconstruction of the aorta and great vessels all demonstrating the catheter entering the right brachiocephalic artery and coursing into the descending aorta. (E) This required treatment with endovascular stent graft placement over the arterial puncture site in the right brachiocephalic artery (black arrow).

Figure 20 A 47-year-old female with end stage renal disease and an arteriovenous fistula with slow flow. (A) Angiographic images of the arteriovenous fistula demonstrating stenosis, which was treated with balloon angioplasty. (B) Angioplasty caused a vascular rupture (black arrow) which was treated with prolonged balloon inflation. hemothorax, pseudoaneurysms, dissection, AV fistula, limb Musculoskeletal ischemia, stroke, or death (85,86). Bone marrow biopsy

Iatrogenic injury during bone marrow biopsy is rare, but Dialysis interventions has been reported in the literature (95). Reported cases of The number of patients treated with dialysis has been arterial injury include circumflex iliac artery, iliolumbar steadily increasing every year, and adequate vascular access artery, superior gluteal artery, median sacral artery, is needed for long term dialysis (87). Arteriovenous fistulas and anterior hypogastric artery (86,96-101). Although and arteriovenous grafts are two commonly used methods complication is rare, the most commonly reported for dialysis access, however these are prone to stenosis (87). complications include infection, hemorrhage, nerve injury, Percutaneous interventions can be used to maintain patency fracture, or needle tract seeding (95) (Figure 21). and increase the life of the fistula or graft (87). Angioplasty is commonly used to treat graft and fistula stenosis over Discussion and summary 50% (87,88). Multiple studies have reported 50% success using angioplasty for maintenance of graft and fistula Iatrogenic injury is an unfortunate risk of medical patency at 6-month and 1-year (89-91). The most common intervention. Adequate training, experience, and image complication of angioplasty is vessel rupture, which can guidance (such as real time ultrasound) can lower procedure often be treated with temporary balloon tamponade or complication rates; however, complications are not stent placement (92) (Figure 20). Cutting balloons and completely avoidable. Prompt recognition of iatrogenic inappropriate balloon selection has been shown to increase injury and appropriate triage for further treatment can the risk of rupture without increase in patency rates (93,94). improve patient outcomes. Minimally invasive endovascular

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Figure 21 A 71-year-old female status post bone marrow biopsy with back and hip pain. (A) Contrast enhanced CT of the abdomen and pelvis demonstrating a large pseudoaneurysm (white arrow) in the expected location of the superficial circumflex iliac artery. (B) Angiographic images of the internal iliac artery demonstrating a large pseudoaneurysm (black arrow) arising from the right superficial circumflex iliac artery. (C,D,E) This was treated with coil embolization. treatment is a potential option for patients with iatrogenic Footnote vascular injury in certain cases. Given the nature of iatrogenic Provenance and Peer Review: This article was commissioned injury, much of the reviewed research was either retrospective by the Guest Editor (Keith Bertram Quencer) for the series or case reports, and thus limited by their design. Further “Endovascular interventions in trauma” published in Annals research is needed to help identify risk factors that would of Translational Medicine. The article was sent for external place a patient at greater risk of harm than benefit from an peer review organized by the Guest Editor and the editorial intervention. Further research is also needed to better define office. outcomes for patients with iatrogenic vascular injury treated with minimally invasive endovascular techniques verses Reporting Checklist: The authors have completed the conservative management or surgical intervention. Narrative Review reporting checklist. Available at http:// dx.doi.org/10.21037/atm-20-4332 Acknowledgments Conflicts of Interest: All authors have completed the ICMJE Finding: None. uniform disclosure form (available at http://dx.doi.

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